Palliation of Opioid-Induced Constipation

Total Page:16

File Type:pdf, Size:1020Kb

Palliation of Opioid-Induced Constipation 7/6/2016 DEFINITIONS • Opioid-Induced Constipation (OIC) vs 2016 ANNUAL MEETING Reflux Bloating • Opioid-Induced Bowel Dysfunction (OIBD) Abdominal cramping motility Hard/dry stools PALLIATION OF OPIOID-INDUCED coordination of sphincter function Incomplete evacuation CONSTIPATION: WHAT’S NEW coordination of secretion Shelley S. Spradley, PharmD, BCPS Clinical Pharmacy Specialist: Pain Management, Palliative Care Poulsen et al. 2015. 2016 ANNUAL MEETING OBJECTIVES OIBD/OIC PREVALENCE & IMPACT • Review prevalence and impact of opioid-induced ** Lack of uniform definition, interpret with caution ** constipation (OIC) • OIC probably most well characterized adverse event in opioid-treated patients • 15-81% in patients without cancer • Discuss the available treatment options for OIC with an • Multinational, internet-based survey of 322 chronic opioid users: 81% despite use emphasis on pathophysiology of laxatives • Larger, population-based survey of 2055 pts on opioids + laxatives for chronic non- • Devise a therapeutic plan to incorporate new cancer pain: 57% prevalence of constipation pharmacologic agents for refractory constipation 1. Moore RA et al. 2005. 2. Bell TJ et al. 2009. 2016 ANNUAL MEETING 2016 ANNUAL MEETING CASE TOWARDS A CONSENSUS DEFINITION OF OIC • 46yo WF with PMH significant for stage V breast cancer, left sided malignant pleural effusion s/p PleurX catheter A change when initiating opioid therapy from baseline presenting with shortness of breath. Medicine team bowel habits that is characterized by any of the following: consult for pharmacy pain evaluation due to high dose opioid analgesics and non-formulary Relistor • Reduced bowel movement frequency • Morphine SA 300mg po q8h • Development or worsening of straining to pass bowel • Hydromorphone 16mg po q3h prn movements • Metoclopramide 10mg po tid • Docusate 100mg po bid • Sense of incomplete rectal evacuation • Senna 17.2mg po bid • Harder stool consistency • Polyethylene glycol 17grams po bid • Methylnaltrexone(Relistor) 12mg/0.6ml SubQ q48h Camilleri M et al. 2014. 2016 ANNUAL MEETING 2016 ANNUAL MEETING 1 7/6/2016 ASSESSMENT TOOLS TREATMENT • Currently, laxatives are primary • Bowel Function Index (BFI) treatment of OIBD • Newer agents • Lubipristone (Amitiza) • Patient Assessment of Constipation-Symptoms • Previously approved peripherally acting • Naloxegel (Movantik) • Bristol Stool Chart mu opioid receptor antagonists (PAMORAs) • TD-1211 (Axelopran) • Electronic Bowel Function Diary • Methylnaltrexone (Relistor) • Naloxone Sustained Release • Alvimopan (Entereg) 1. Morlion B et al. 2015. 2. Frank L et al. 1999. 3. Lewis SJ et al. 1997. 1. Coyne KS et al. 2014 4. Camilleri M. 2011. 2. Siemens W et al. 2015 2016 ANNUAL MEETING 2016 ANNUAL MEETING PATHOPHYSIOLOGY LET’S NOT FORGET…. • 3 types of opioid receptors involved in controlling normal GI function • Mu, Delta, Kappa • Many patients have inadequate traditional bowel regimens • Docusate, senna/bisacodyl, lactulose, sorbitol, • Endogenous and exogenous opioids activate Mu receptors polyethylene glycol, steroids(obstruction), prune • Ultimately inhibit conversion of ATP to cAMP, reduce cellular functions juice, various enemas and suppositories, manual dis-impaction, digital rectal stimulation... • Opioids also directly activate K+ channels and inhibit Ca2+ • Failure of “prn” bowel regimens does not • Net result = reduced release of neurotransmitters, necessitate escalation to new, costly agents decreased neuronal activity 1. Holzer P. 2004. 2. Holzer P. 2009. 2016 ANNUAL MEETING 2016 ANNUAL MEETING PATHOPHYSIOLOGY DRIVING TREATMENT OLDER AGENTS 1. Dryer, harder stool Methylnaltrexone (Relistor) Almivopan (Entereg) MOA PAMORA PAMORA 2. Feeling of incomplete evacuation FDA • OIC including in advanced illness • Post-operative ileus following certain Indications patients receiving palliative care surgeries • FDA warning for bowel perforation in Warnings • BBW, active REMS program advanced cancer patients 3. Reduced propulsive peristalsis • 12mg SubQ every other day prn • 12mg PO 30min-5hr prior to sx Dosing • Max 1 dose/24hr • 12mg PO bid starting day after sx for ≤ 7d • Weight and renal dose adjustments • Renal and hepatic dose adjustments 1. Holzer P. 2004 1. Thomas J et al. 2008 2. Holzer P. 2009 2. Jansen JP et al. 2011. 3. Holder RM et al. 2016. 3. Merck & Co Inc. 2015 2016 ANNUAL MEETING 2016 ANNUAL MEETING 2 7/6/2016 NEWER AGENTS ON THE HORIZON Sustained Release Pearls from Clinical Studies Lubiprostone (Amitiza) Pearls from Clinical Studies Naloxone (NSR) MOA Chloride channel activator • Significant increase in spontaneous bowel movements Modified release reduces • 40 patients randomized in blocks to receive 2.5mg, MOA systemic concentrations, acts • CIC (2006), IBS (2008) (SBMs)/week compared to placebo 5mg, 10mg or 20mg FDA Indications like a PAMORA • 6 week study, doses inc’d to BID at week 4 • OIC (2013) • Median time to 1st BM 28.5h (not different than placebo) • Not approved as single agent • At week 3, mean change in SBMs/week was • Long-term efficacy over 9 months found inc’d number of FDA • Oxycodone ER/naloxone statistically significant compared to placebo for only SBMs/week from 1.4 at baseline to 4.9 Indications • 24mcg PO BID with food fixed combo approved 20mg and water • Not superior to placebo in reliance on rescue therapy w/ Dosing • At week 6, only 10mg BID dose achieved statistical • Dose adjusted for laxative • 2.5mg/day - 40mg/day orally significance compared to placebo hepatic impairment has been studied • Improvements in OIBD symptoms noted (straining, Dosing • OxyER/naloxone not being • Opioid withdrawal: no statistically significant change severity of constipation, bloating) manufactured from baseline or compared to placebo 1. Cryer B et al 2014. 1. Holder RM et al. 2016. 2. Jamal MM et al. 2015. 2. Sanders M et al. 2015. 2016 ANNUAL MEETING 2016 ANNUAL MEETING NEWER AGENTS CASE REVISITED Naloxegol (Movantik) Pearls from Clinical Studies • 46yo WF with PMH significant for stage V breast cancer MOA Pegylated naloxone derivative • KODIAC 04, KODIAC 05 • Last BM 4 days prior FDA Indications • OIC in CNCP (2014) • Statistically significant improvements in straining, stool consistency, and complete spontaneous • Normal: BM every other day, bristol stool type 2, endorses moderate • 25mg po daily, empty stomach bowel movement (SBM) straining with each BM, frequent feeling of incomplete evacuation • 12.5mg achieved significantly greater • Reduce to 12.5mg for: response than placebo in KODIAC 04 only • Scenario 1 • Intolerance • 25mg dose reach statistical significance in • Continue current bowel regimen, including methylnaltrexone 12mg SubQ q48hr Dosing both studies • CrCl less than 60ml/min • Add docusate mini enema (Enemeez), 2 enema NOW PR then q48hr • Co-administered with • 25mg dose resulted in shorter median time moderate CYP3A4 to first SBM • Scenario 2 inhibitors • No significant difference in bisacodyl use • Discontinue methylnaltrexone, continue docusate, senna, polyethylene glycol between treatment arms • Add enema or suppository “NOW” dose 1. Chey WD et al. 2014. 2. Webster L et al. 2014. • Add lubipristone 24mcg PO BID with food, water 3. Holder RM et al. 2016. 2016 ANNUAL MEETING 2016 ANNUAL MEETING ON THE HORIZON CLINICAL PEARLS TD-1211 (Axelopran) Pearls from Clinical Studies • Safe to assume opiates/opioids constipate everyone MOA PAMORA • Efficacy evaluated in three phase 2 studies • Bowel regularity assessment should include discussion FDA beyond frequency • Not yet approved Indications • Definitions of OIC, spontaneous bowel movement (SBM) or complete SBM were not provided • Pathophysiology of OIC/OIBD often results in dry/hard stools, incomplete evacuation, and reduced propulsive • No formal • Doses of 5 and 10mg produced greatest SBMs/week peristalsis recommendation, has • Median time to first SBM 8.6hrs (5mg) and 3.6hrs Dosing been studied most (10mg) compared to 28.7hr(placebo) • Newer agents do not replace standard of care recently at 5mg, 10mg, • Many agents were only studied against placebo 15mg orally • Studies reported no clinically significant changes in lab tests, ECG, or vital signs (but did not report the data) • Rescue laxatives were required in most clinical studies 1. Holder RM et al. 2016. 2. Axelopran (TD-1211) briefing document: 2014 2016 ANNUAL MEETING 2016 ANNUAL MEETING 3 7/6/2016 REFERENCES • Poulsen JL, Brock C, Olesen AE et al. Evolving paradigms in treatment of opioid-induced bowel dysfunction. Ther Adv Gastroenterol 2015;8(6):360-72. • Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: a systematic review of randomised trials of oral opioids. Arthritis Res Ther 2005;7:R1046-51 • Bell TJ, Panchal SJ, Miaskowski C et al. The prevalence, severity and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Med 2009;10:35-42. • Camilleri M, Drossman DA, Becker G et al. Emerging treatments in neurogastroenterology: a multidisciplinary working group concensus statement on opioid- induced constipation. Neurogastroenterol Motil 2014; 26(10):1386-95 • Morlion B, Clemens KE, Dunlop W. QuaIity of life and healthcare resource in patients receiving opioids for chronic pain: a review of the place of oxycodone/naloxone. Clin Drug Investig 2015;35(1):1-11. • Frank L, Kleinman L, Farup C et al. Psychometric validation of a constipation assessment questionnaire. Scan J Gastroenterol 1999;34(9):870-77. • Lewis SJ, Heaton KW. Stool form scale as a useful guide to
Recommended publications
  • Naloxegol (Movantik) Reference Number: ERX.NSMN.02 Effective Date: 07/16 Last Review Date: 03/16
    Clinical Policy: naloxegol (Movantik) Reference Number: ERX.NSMN.02 Effective Date: 07/16 Last Review Date: 03/16 Clinical policies are intended to be reflective of current scientific research and clinical thinking. This policy is current at the time of approval, may be updated and therefore is subject to change. This Clinical Policy is not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding payment or results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This policy is the property of Envolve Pharmacy Solutions. Unauthorized copying, use, and distribution of this Policy or any information contained herein is strictly prohibited. By accessing this policy, you agree to be bound by the foregoing terms and conditions, in addition to the Site Use Agreement for Health Plans associated with Envolve Pharmacy Solutions. Description The intent of the criteria is to ensure that patients follow selection elements established by Envolve Pharmacy Solutions for the use of naloxegol (MovantikTM). Policy/Criteria It is the policy of health plans affiliated with Envolve Pharmacy Solutions that naloxegol (Movantik) is medically necessary for members meeting the following criteria: Initial Approval Criteria: I. Opioid-Induced Constipation (OIC) (must meet all) A. Age is ≥ 18 years old; B. Diagnosis of opioid-induced constipation; C. Member has used an opioid analgesic ≥ 4 weeks; D. Member is not being treated for cancer pain; E. Member has failed ≥ 2 non-bulk forming laxatives (see Table A) from different classes while on opioid therapy, unless contraindicated; F.
    [Show full text]
  • RELISTOR, INN: Methylnaltrexone Bromide
    The European Medicines Agency Evaluation of Medicines for Human Use EMEA/CHMP/10906/2008 ASSESSMENT REPORT FOR RELISTOR International Nonproprietary Name: METHYLNALTREXONE BROMIDE Procedure No. EMEA/H/C/870 Assessment Report as adopted by the CHMP with all information of a commercially confidential nature deleted. 7 Westferry Circus, Canary Wharf, London, E14 4HB, UK Tel. (44-20) 74 18 84 00 Fax (44-20) 74 18 8613 E-mail: [email protected] http://www.emea.eu.int TABLE OF CONTENTS Page 1 BACKGROUND INFORMATION ON THE PROCEDURE......................................... 3 1.1 Submission of the dossier ...................................................................................................... 3 1.2 Steps taken for the assessment of the product ....................................................................... 3 2 SCIENTIFIC DISCUSSION............................................................................................... 4 2.1 Introduction............................................................................................................................ 4 2.2 Quality aspects....................................................................................................................... 5 2.3 Non-clinical aspects............................................................................................................... 7 2.4 Clinical aspects .................................................................................................................... 13 2.5 Pharmacovigilance...............................................................................................................41
    [Show full text]
  • Albany-Molecular-Research-Regulatory
    PRODUCT CATALOGUE API COMMERCIAL US EU Japan US EU Japan API Name Site CEP India API Name Site CEP India DMF DMF DMF DMF DMF DMF A Abiraterone Malta • Benztropine Mesylate Cedarburg • Adenosine Rozzano - Quinto de' Stampi • • * Betaine Citrate Anhydrous Bon Encontre • Betametasone-17,21- Alcaftadine Spain Spain • • Dipropionate Sterile • Alclometasone-17, 21- Spain Betamethasone Acetate Spain Dipropionate • • Altrenogest Spain • • Betamethasone Base Spain Amphetamine Aspartate Rensselaer Betamethasone Benzoate Spain * Monohydrate Milled • Betamethasone Valerate Amphetamine Sulfate Rensselaer Spain * • Acetate Betamethasone-17,21- Argatroban Rozzano - Quinto de' Stampi Spain • • Dipropionate • • • Atenolol India • • Betamethasone-17-Valerate Spain • • Betamethasone-21- Atracurium Besylate Rozzano - Quinto de' Stampi Spain • Phosphate Disodium Salt • • Bromfenac Monosodium Atropine Sulfate Cedarburg Lodi * • Salt Sesquihydrate • • Azanidazole Lodi Bromocriptine Mesylate Rozzano - Quinto de' Stampi • • • • • Azelastine HCl Rozzano - Quinto de' Stampi • • Budesonide Spain • • Aztreonam Rozzano - Valle Ambrosia • • Budesonide Sterile Spain • • B Bamifylline HCl Bon Encontre • Butorphanol Tartrate Cedarburg • Beclomethasone-17, 21- Spain Capecitabine Lodi Dipropionate • C • 2 *Please contact our Accounts Managers in case you are interested in this API. 3 PRODUCT CATALOGUE API COMMERCIAL US EU Japan US EU Japan API Name Site CEP India API Name Site CEP India DMF DMF DMF DMF DMF DMF Dexamethasone-17,21- Carbimazole Bon Encontre Spain • Dipropionate
    [Show full text]
  • 204760Orig1s000
    CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 204760Orig1s000 OTHER REVIEW(S) MEMORANDUM DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION CENTER FOR DRUG EVALUATION AND RESEARCH DATE: September 16, 2014 FROM: Julie Beitz, MD SUBJECT: Approval Action TO: NDA 204760 Movantik (naloxegol) tablets AstraZeneca Pharmaceuticals LP Summary Naloxegol is an antagonist of opioid binding at the muͲopioid receptor. When administered at the recommended dose levels, naloxegol functions as a peripherallyͲacting opioid receptor antagonist in tissues such as the gastrointestinal tract, thereby decreasing the constipating effects of opioids. Naloxegol is a PEGylated derivative of naloxone and a new molecular entity. Pegylation confers the following properties: naloxegol has reduced passive permeability across membranes compared to naloxone; naloxegol is a PͲglycoprotein (PͲgp) efflux transporter substrate; and naloxegol is orally bioavailable. The reduced passive permeability and PͲgp efflux transporter properties limit CNS entry of naloxegol compared to naloxone. This memo documents my concurrence with the Division of Gastroenterology and Inborn Errors Product’s recommendation for approval of NDA 204760 for Movantik (naloxegol) tablets for the treatment of opioidͲinduced constipation (OIC) in adult patients with chronic nonͲcancer pain. Discussions regarding product labeling, and postmarketing study requirements and commitments have been satisfactorily completed. There are no inspectional issues that preclude approval. Dosing The recommended dose of Movantik (naloxegol) tablets is 25 mg taken once daily in the morning on an empty stomach. Patients who do not tolerate this dose, may reduce the dose to 12.5 mg once daily. Maintenance laxatives should be discontinued prior to initiation of therapy with Movantik.
    [Show full text]
  • Design and Synthesis of Cyclic Analogs of the Kappa Opioid Receptor Antagonist Arodyn
    Design and synthesis of cyclic analogs of the kappa opioid receptor antagonist arodyn By © 2018 Solomon Aguta Gisemba Submitted to the graduate degree program in Medicinal Chemistry and the Graduate Faculty of the University of Kansas in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Chair: Dr. Blake Peterson Co-Chair: Dr. Jane Aldrich Dr. Michael Rafferty Dr. Teruna Siahaan Dr. Thomas Tolbert Date Defended: 18 April 2018 The dissertation committee for Solomon Aguta Gisemba certifies that this is the approved version of the following dissertation: Design and synthesis of cyclic analogs of the kappa opioid receptor antagonist arodyn Chair: Dr. Blake Peterson Co-Chair: Dr. Jane Aldrich Date Approved: 10 June 2018 ii Abstract Opioid receptors are important therapeutic targets for mood disorders and pain. Kappa opioid receptor (KOR) antagonists have recently shown potential for treating drug addiction and 1,2,3 4 8 depression. Arodyn (Ac[Phe ,Arg ,D-Ala ]Dyn A(1-11)-NH2), an acetylated dynorphin A (Dyn A) analog, has demonstrated potent and selective KOR antagonism, but can be rapidly metabolized by proteases. Cyclization of arodyn could enhance metabolic stability and potentially stabilize the bioactive conformation to give potent and selective analogs. Accordingly, novel cyclization strategies utilizing ring closing metathesis (RCM) were pursued. However, side reactions involving olefin isomerization of O-allyl groups limited the scope of the RCM reactions, and their use to explore structure-activity relationships of aromatic residues. Here we developed synthetic methodology in a model dipeptide study to facilitate RCM involving Tyr(All) residues. Optimized conditions that included microwave heating and the use of isomerization suppressants were applied to the synthesis of cyclic arodyn analogs.
    [Show full text]
  • Moventig, INN-Naloxegol
    Package leaflet: Information for the patient Moventig 12.5 mg film-coated tablets Moventig 25 mg film-coated tablets naloxegol Read all of this leaflet carefully before you start taking this medicine because it contains important information for you. - Keep this leaflet. You may need to read it again. - If you have any further questions, ask your doctor, pharmacist or nurse. - This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours. - If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. See section 4. What is in this leaflet 1. What Moventig is and what it is used for 2. What you need to know before you take Moventig 3. How to take Moventig 4. Possible side effects 5. How to store Moventig 6. Contents of the pack and other information 1. What Moventig is and what it is used for Moventig contains the active substance naloxegol. It is a medicine used in adults to treat constipation specifically caused by pain medicines, called opioids, (e.g. morphine, oxycodone, fentanyl, tramadol, codeine) taken on a regular basis. It is used when laxatives have not provided acceptable relief of constipation. Constipation related to opioids can result in symptoms such as: • stomach pain • rectal straining (having to push very hard to move the stool out of the rectum, which can also cause pain in the anus during pushing) • hard stools (stools which are hard “like a rock”) • incomplete emptying of the rectum (after having a bowel movement, the feeling as if a stool is still in the rectum which needs to come out) In patients taking opioids with constipation, who have tried at least one laxative and had incomplete relief of constipation, Moventig has been shown in clinical trials to increase the number of bowel movements and improve symptoms of constipation caused by opioids.
    [Show full text]
  • Opioids in Palliative Care: Evidence Update May 2014
    Opioids in palliative care Evidence Update May 2014 A summary of selected new evidence relevant to NICE clinical guideline 140 ‘Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults’ (2012) Evidence Update 58 Contents Introduction ................................................................................................................................ 3 Key points .................................................................................................................................. 4 1 Commentary on new evidence .......................................................................................... 5 1.1 Communication .......................................................................................................... 5 1.2 Starting strong opioids – titrating the dose ................................................................ 5 1.3 First-line maintenance treatment ............................................................................... 6 1.4 First-line treatment if oral opioids are not suitable – transdermal patches ................ 6 1.5 First-line treatment if oral opioids are not suitable – subcutaneous delivery ............. 7 1.6 First-line treatment for breakthrough pain in patients who can take oral opioids ...... 7 1.7 Management of constipation ..................................................................................... 8 1.8 Management of nausea ..........................................................................................
    [Show full text]
  • A Review of Unique Opioids and Their Conversions
    A Review of Unique Opioids and Their Conversions Jacqueline Cleary, PharmD, BCACP Assistant Professor Albany College of Pharmacy and Health Sciences Adjunct Professor SAGE College of Nursing DISCLOSURES • Kaleo • Remitigate, LLC OBJECTIVES • Compare and contrast unique pharmacotherapy options for the treatment of chronic pain including: methadone, buprenoprhine, tapentadol, and tramadol • Select methadone, buprenorphine, tapentadol, or tramadol based on patient specific factors • Apply appropriate opioid conversion strategies to unique opioids • Understand opioid overdose risk surrounding opioid conversions and the use of unique opioids UNIQUE OPIOIDS METHADONE, BUPRENORPHINE, TRAMADOL, TAPENTADOL METHADONE My favorite drug because….? METHADONE- INDICATIONS • FDA labeled indications – (1) chronic pain (2) detoxification Oral soluble tablets for suspension NOT indicated for chronic pain treatment • Initial inpatient detoxification of opioids by a licensed trained provider with methadone and supportive care is appropriate • Methadone maintenance provider must have special credentialing and training as required by state Outpatient prescription must be for pain ONLY and say “for pain” on RX • Continuation of methadone maintenance from outside provider while patient is inpatient for another condition is appropriate http://cdn.atforum.com/wp-content/uploads/SAMHSA-2015-Guidelines-for-OTPs.pdf MECHANISM OF ACTION • Potent µ-opioid agonist • NMDA receptor antagonist • Norepinephrine reuptake inhibitor • Serotonin reuptake inhibitor ADVERSE EVENTS
    [Show full text]
  • Methylnaltrexone Nonf
    Methylnaltrexone Bromide Subcutaneous Injection and Tablets Criteria for Use May 2020 VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives The following recommendations are based on medical evidence, clinician input, and expert opinion. The content of the document is dynamic and will be revised as new information becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost- effective drug prescribing. THE CLINICIAN SHOULD USE THIS GUIDANCE AND INTERPRET IT IN THE CLINICAL CONTEXT OF THE INDIVIDUAL PATIENT. INDIVIDUAL CASES THAT ARE EXCEPTIONS TO THE EXCLUSION AND INCLUSION CRITERIA SHOULD BE ADJUDICATED AT THE LOCAL FACILITY ACCORDING TO THE POLICY AND PROCEDURES OF ITS P&T COMMITTEE AND PHARMACY SERVICES. The Product Information should be consulted for detailed prescribing information. Exclusion Criteria If ANY item below applies, the patient should NOT receive methylnaltrexone subcutaneous injections. Known or suspected mechanical gastrointestinal obstruction or other condition that may compromise drug action or cause bowel dysfunction (e.g., acute abdomen, ostomy, active diverticulitis, ischemic bowel, etc.) Placement of peritoneal catheter for chemotherapy or dialysis (not studied) End-stage renal impairment on dialysis (not studied) Use of methylnaltrexone solely for prevention of opioid-induced constipation or impaction (no supporting evidence). Use of methylnaltrexone for postoperative ileus (preliminary results showed inefficacy). Use of methylnaltrexone for constipation that is not opioid-related (not studied) Concomitant use of other opioid antagonists (potential for increased risks of additive effects and opioid withdrawal) Inclusion Criteria for Opioid-induced Constipation in Adults with Chronic Noncancer Pain All of the following criteria must be fulfilled.
    [Show full text]
  • Prescriber Update Vo.39 No.2. June 2018
    Prescriber Update Vol. 39 No. 2 June 2018 www.medsafe.govt.nz ISSN 1172-5648 (print) ISSN 1179-075X (online) Contents Spotlight on Codeine 18 Making Medicines Safer: New e-Learning Module on Reporting Adverse Reactions Launched 19 Tenofovir Disoproxil – a Salty Tale 20 Medicines Interacting with Methadone 20 Hyoscine Butylbromide Injection and Cardiovascular Adverse Reactions 22 Using New Zealand Data to Review the Risk of Venous Thromboembolism with Combined Oral Contraceptives 23 Hypocalcaemia – a Risk with Zoledronic Acid 24 Pharmacogenomics – Helps Reduce Rash Decisions 25 MARC’s Remarks: March 2018 Meeting 27 Gathering Knowledge from Adverse Reaction Reports: June 2018 28 Medicines Monitoring: Dabigatran and gout or gout-like symptoms 29 Recent Approvals of Medicines Containing a New Active Ingredient 29 The Medsafe Files – Episode Six: Global Pharmacovigilance 29 Correction: Adverse Reaction Reporting in New Zealand – 2017 30 Medicine Classification Update – November 2017 31 Quarterly Summary of Recent Safety Communications 31 Report Adverse Drug Reactions 31 Subscribe to Prescriber Update 32 Spotlight on Codeine Key Messages phenotypes varies between populations. The relative frequencies of these phenotypes in the z The following patients should not use New Zealand population are not known. codeine as the risks of harm outweigh Poor metabolisers are unable to convert codeine any benefit: to morphine and receive little if any, analgesic – children aged under 12 years benefit. Extensive metabolisers convert 5–15% – adolescents aged under 18 years: for of codeine to morphine via the CYP2D6 enzyme. pain following surgery to remove In these patients, a 30 mg dose of codeine tonsils or adenoids, for symptomatic phosphate would yield approximately 1.5 mg to relief of cough, or in patients whose 4.5 mg of morphine.
    [Show full text]
  • Therapeutic Class Overview Irritable Bowel Syndrome and Constipation Agents
    Therapeutic Class Overview Irritable Bowel Syndrome and Constipation Agents INTRODUCTION Irritable bowel syndrome (IBS) is a gastrointestinal disorder that most commonly manifests as chronic abdominal pain and altered bowel habits in the absence of any organic disorder (Wald 2017). IBS may consist of diarrhea-predominant (IBS-D), constipation-predominant (IBS-C), IBS with a mixed symptomatology (IBS-M), or unclassified IBS (IBS-U). Switching between the subtypes of IBS is also possible (Ford et al 2014). IBS is a functional disorder of the gastrointestinal tract characterized by abdominal pain, discomfort, and bloating, as well as disturbed bowel habit. The exact pathogenesis of the disorder is unknown; however, it is believed that altered gastrointestinal tract motility, visceral hypersensitivity, autonomic dysfunction, and psychological factors indicate disturbances within the enteric nervous system, which controls the gastrointestinal system (Andresen et al 2008, Ford et al 2009). Prevalence estimates of IBS range from 5 to 15%, and it typically occurs in young adulthood (Ford et al 2014). IBS-D is more common in men, and IBS-C is more common in women (World Gastroenterology Organization [WGO], 2015). Symptoms of IBS often interfere with daily life and social functioning (WGO 2015). The general goals of therapy are to alleviate the patient’s symptoms and to target any specific exacerbating factors (eg, medications, dietary changes), concerns about serious illness, stressors, or potential psychiatric comorbidities that may exist (Wald 2015). Non-pharmacological interventions to combat IBS symptoms include dietary modifications such as exclusion of gas- producing foods (eg, beans, prunes, Brussel sprouts, bagels, etc.), trials of gluten avoidance, and consumption of probiotics, as well as psychosocial therapies (eg, hypnosis, biofeedback, etc.) (Ford et al 2014).
    [Show full text]
  • 208854Orig1s000
    CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 208854Orig1s000 SUMMARY REVIEW OND=Office of New Drugs OPQ=Office of Pharmaceutical Quality OPDP=Office of Prescription Drug Promotion OSI=Office of Scientific Investigations CDTL=Cross-Discipline Team Leader COA=Clinical Outcome Assessment CSS=Controlled Substance Staff DAAAP= Division of Anesthesia, Analgesia, and Addiction Products OSE= Office of Surveillance and Epidemiology DEPI= Division of Epidemiology DMEPA=Division of Medication Error Prevention and Analysis DPMH = Division of Pediatric and Maternal Health MHT=Maternal Health Team Quality Review Team DISCIPLINE REVIEWER BRANCH/DIVISION Drug Substance Joseph Leginus CDER/OPQ/ONDP/ DNDAPI/NDBII Drug Product Sarah Ibrahim CDER/OPQ/ONDP/ DNDPII/NDPBV Process Zhao Wang CDER/OPQ/OPF/ DPAI/PABI Microbiology Zhao Wang CDER/OPQ/OPF/ DPAI/PABI Facility Donald Lech CDER/OPQ/OPF/DIA/IABIII Biopharmaceutics Peng Duan CDER/OPQ/ONDP/ DB/BBII Regulatory Business Cheronda Cherry-France CDER/OND/ODEIII/ DGIEP Process Manager Application Technical Lead Hitesh Shroff CDER/OPQ/ONDP/ DNDPII/NDPBV Laboratory (OTR) N/A N/A ORA Lead Paul Perdue Jr. ORA/OO/OMPTO/ DMPTPO/MDTP Environmental Analysis James Laurenson CDER/OPQ/ONDP (EA) 2 Reference ID: 4073992 1. Benefit-Risk Assessment I concur with the reviewers’ conclusions that the benefit/risk of naldemedine is favorable in the population for which this product will be approved and that the risks can be managed with labeling. The applicant proposed the following indication for naldemedine, an orally administered peripheral mu opioid receptor antagonist: Symproic is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain.
    [Show full text]